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United States Patent |
5,674,074
|
Angelo, Jr.
|
October 7, 1997
|
Periodontal procedure
Abstract
A novel periodontal procedure for performing periodontal treatment
including the steps of applying anesthetic to the area to be treated and
making an incision on the facial side of the most posterior tooth and
continuing the incision toward the most anterior tooth. The incision
begins at the distal facial line angle of the most posterior tooth on the
facial side of the arch and is made at about a forty-five degree angle to
the plane of the tooth, forming an inverse bevel within the coronal
portion of the pocket. A similar incision is made on the lingual side in
the same manner. The incision is reentered to separate the facial,
lingual, and papillary tissues from the underlying connective tissue so
that the separated facial, lingual, papillary tissue may be removed,
thereby removing the coronal portion of the tissue pocket and initially
exposing root surfaces. The remaining tissue pocket is then removed. Soft
tissue tags adjacent to the incised areas are also removed. Next, gross
bacterial accretions on the root surface are removed followed by fine
bacterial accretion removal. Post-treatment procedures to aid healing
include light scaling of the teeth in the treated area followed by
polishing of the teeth in the treated area with fluoride prophylaxis
material and applying about a 30% trichloracetic acid to the facial,
lingual, and proximal areas about seven days after treatment. The
post-operative procedure is repeated seventeen days and thirty-one days
after treatment.
Inventors:
|
Angelo, Jr.; Patrick J. (722 N. Prospect, Park Ridge, IL 60068)
|
Appl. No.:
|
405547 |
Filed:
|
June 13, 1996 |
Current U.S. Class: |
433/215 |
Intern'l Class: |
A61C 005/00 |
Field of Search: |
423/215,216
|
References Cited
U.S. Patent Documents
5006071 | Apr., 1991 | Carter | 433/215.
|
5093179 | Mar., 1992 | Scantlebury et al. | 433/215.
|
5418221 | May., 1995 | Hammarstrom et al. | 433/215.
|
5455041 | Oct., 1995 | Genco et al. | 433/215.
|
Primary Examiner: Lucchesi; Nicholas D.
Attorney, Agent or Firm: Brezina & Ehrlich
Claims
What is claimed is:
1. A method for performing periodontal treatment for removing gingival
tissue pockets and to gain access to a root surface of at least one tooth
of a series of teeth for removing bacterial accretions upon said one
tooth, the method comprising the steps of:
applying anesthetic to an area to be treated;
making a first incision on the facial side of a most posterior tooth of the
series of teeth and continuing the incision toward a most anterior tooth
of the series of teeth;
said first incision beginning at the distal facial line angle of said most
posterior tooth;
said first incision being made at about a forty-five degree angle to the
plane of said most posterior tooth forming an inverse bevel;
making a second incision on the lingual side of the most posterior tooth
and continuing the incision toward the most anterior tooth;
said second incision beginning at the distal lingual line angle of said
most posterior tooth;
said second incision being made at about forty-five degree angle to the
plane of said most posterior tooth, forming an inverse bevel;
re-entering said first incision to separate the facial papillary tissues
from underlying connective tissue;
re-entering said second incision to separate the lingual papillary tissues
from underlying connective tissue;
removing the separated facial and lingual papillary tissue thereby removing
a coronal portion of the tissue pocket to initially expose the root
surface;
using a tissue cutting instrument applied at about a forty-five degree
angle to the tooth surface to find an apical extent of the tissue pocket;
removing soft tissue tags attached adjacent to the first and second
incisions;
removing gross bacterial accretions on the root surface;
removing fine bacterial accretions on the root surface; and
performing post-treatment procedures to aid healing.
2. The method of claim 1 wherein said incisions are performed with a blade
having a tip, said tip remaining within the coronal (sulcus) portion of
the tissue pocket for the length of the incisions.
3. The method of claim 1 wherein the steps of performing the incisions are
performed using a scalpel blade.
4. The method of claim 1 wherein the steps of performing the incisions are
performed using an Orban knife.
5. The method of claim 1 wherein the steps of reentering the incisions are
performed using a No. 1/2 Orban knife at about a forty-five degree inverse
bevel angle.
6. The method of claim 1 wherein the steps of removing said separated
tissue are performed using a hemostat.
7. The method of claim 1 wherein the step of removing the soft tissue tags
is performed using a cutting instrument.
8. The method of claim 1 wherein the step of removing gross bacterial
accretions is performed using an ultrasonic scaler.
9. The method of claim 1 wherein the step of removing gross bacterial
accretions is performed using a hand scaling instrument.
10. The method of claim 1 wherein the step of removing the fine bacterial
accretions is performed using a non-end cutting bur.
11. The method of claim 1 further includes the step of applying about 30%
trichloracetic acid to facial, lingual, and papillary tissues after the
step of removing fine bacterial accretions is performed.
12. The method of claim 1 wherein the step of performing post-treatment
procedures further includes the steps of:
performing light scaling of the teeth in the treated area after about seven
days after treatment;
subsequently polishing the teeth in the treated area with fluoride
prophylaxis material and applying about a 30% trichloracetic acid to the
facial, lingual, and proximal tissues;
performing light scaling of the teeth in the treated area after about
seventeen days after treatment;
subsequently polishing the teeth in the treated area with fluoride
prophylaxis material and applying about a 30% trichloracetic acid to the
facial, lingual, and proximal tissues;
performing light scaling of the teeth in the treated area after about
thirty-one days after treatment; and
subsequently polishing the teeth in the treated area with fluoride
prophylaxis material and applying about a 30% trichloracetic acid to the
facial, lingual, and proximal tissues.
13. The method of claim 1 further including the steps of making a sulcular
incision including the palatal half of the maxillary anterior papilla to
gain visual access to the proximal surfaces of the maxillary anterior
sextant from the palatal aspect.
Description
BACKGROUND OF THE INVENTION
With the advent of soft tissue gum management and the Periodontal Screening
and Recording System (PSR), many dental practitioners have become
increasingly aware of patients having generalized five to six millimeter
pocket depths which bleed, may exhibit exudate in response to gentle
probing, and may exhibit horizontal bone loss. Unfortunately, even after
conventional soft tissue gum management has been completed, bacterial
accretions may still exist on root surfaces. Further attachment loss is
risked due to the episodic destructive characteristics of periodontal
disease when bacteria remains on the root surface.
This situation may also be present in patients regressing after
conventional flap surgery. The chances of removing all bacteria from the
root surfaces even in pockets only three to five millimeters deep through
standard scaling and root planing are not predictable. In fact, the
success rate may be less than 50%. The inability to remove accretions in
horizontal bone loss furcations or concavities further complicates
successful therapy.
Historically, curettage with scaling and root planing, gingivectomy, and
gingivoplasty, and various flap procedures have been utilized to remove
bacterial accretions and decrease periodontal pocket depths. Curettage
with scaling and root planing does not ensure that residual plaque and
calculus are removed from the treated surfaces. Sutures may be needed,
depending on fragility of the tissue and the aggressiveness of the
curettage.
Gingivectomy procedures allow treatment of suprabony pockets through the
removal of excessive gingival tissue utilizing a reverse bevel incision,
but leaves a broad wound. Gingivoplasty, which is often done in
conjunction with gingivectomy procedures, produces a broader, deeper wound
than gingivectomy alone. Post-operative recovery can be both painful and
slow. The initial step of the gingivectomy is to measure the base of the
pocket with a pocket marker or a periodontal probe with a series of
bleeding points. The bleeding points are crudely punctured on the outside
of the gingiva to outline the location for the initial incision. These
methods are tedious, time consuming, and often inaccurate if the pocket
marker or probe is tilted, even slightly. An incorrect measurement, most
likely, will result in an incision that may be too deep, thus, producing a
more aggressive and larger wound, or may result in an initial incision
that is too shallow.
In typical gingivectomy procedures, an initial incision is made apical to
the bleeding points with a gingivectomy knife, such as with a Kirkland or
Orban knife. This incision produces an external bevel made forty-five
degrees relative to the tooth surface. The incision usually ends at the
depth apical to the epithelial attachment. A bevel is placed on the tissue
farthest from the tooth and is then lengthened to eliminate a plateau
which would make the wound larger.
Use of an reverse bevel incision causes a broad and traumatic wound. The
apical area of the epithelium attachment need not be removed to gain
access to the root structure and subsequent bacterial debris. Tissue
removal may be accomplished with heavy scalers, hoes or curettes, while
removal of bacterial debris from the tooth surfaces is accomplished with
smaller scalers and curettes. Final contour of the tissue is completed
using a coarse diamond bur or a broad bladed knife. Finally, a large
dressing is placed over the entire wound area.
These procedures require application of an uncomfortable surgical dressing
due to the broad wound. In a majority of gingivectomy surgeries, a
gingivoplasty is performed which reshapes the gingiva to achieve
physiologic contours. This is performed with sharp periodontal knives in a
scraping motion on the surface of the gum or with a coarse diamond rotary
bur abrading the surface of the gingiva. Both the periodontal knife and
coarse diamond burs leave deep wounds resulting in delayed healing,
increased post-operative pain, and an increased chance of bleeding. With
gingivectomy procedures, maxillary anterior esthetics are severely
compromised due to gross removal of facial tissue of the affected teeth.
Alternatively, gingival flap procedures expose bone which generally, will
be partially resorbed depending on the thinness of bone and the length of
time that the gingival flap is raised. Furthermore, flap procedures which
are typically performed on deeper pockets with bleeding on probing and
vertical bone loss, require a high degree of skill and may cause the
patient moderate to severe pain, swelling, and discoloration.
Additionally, suturing is required. In flap surgery, the gum is separated
from the tooth to expose the root surface and bone. Then, the separated
flaps of gum are sutured back to each other in between each tooth after
debridement has been completed.
SUMMARY OF THE INVENTION
The need for a more conservative procedure to gain visual access to the
root surface affects a large number of existing patients. The inventive
periodontal procedure according to the present inventive method
substantially overcomes the above problems. The inventive periodontal
procedure provides greater access to the root surface than scaling and
root planing, is less invasive than flap procedures, and is less traumatic
than a standard gingivectomy with or without accompanying gingivoplasty.
Periodontal disease is site specific. Accordingly, the periodontal
procedure is a site-specific procedure. Many patients with generalized
five to six millimeter pockets who bleed and may exhibit exudate in
response to gentle probing are more likely to have the destructive pattern
of periodontal disease.
The inventive periodontal procedure is an alternative to flap procedures or
gingivectomy procedures. The patient's bony pattern (i.e., horizontal or
vertical), rather than the amount of bone loss, must be considered.
Patients most likely to benefit from conservative access therapy are those
with symptoms of chronic adult periodontitis which results in episodic
attachment loss. The present periodontal procedure may stop the
progression of attachment loss in areas where regressing pockets of
generalized five to six millimeters in depth where bleeding upon gentle
probing and horizontal bone loss are evident. The clinical objective is to
gain visual access to the root surface while causing minimum trauma to the
patient.
This procedure is contraindicated in patients having mucogingival defects,
severe hyperplastic tissue, vertical bone loss, and deep pocketing on the
facial aspects of the maxillary anterior sextant. In the absence of such
contraindications, the novel periodontal procedure offers many advantages
over flap procedures, or standard gingivectomy such as less traumatic
complete access to subgingival bacterial accretions, reducing pockets to
facilitate patient maintenance, minimal patient trauma and bleeding,
decreased post-operative discomfort, no swelling of the jaw, and no
discoloration of the facial tissues. The advantage versus scaling is
predictability of pocket reduction to facilitate patient maintenance due
to predictable elimination of bacterial accretions.
The periodontal procedure includes the steps of applying local anesthetic
to the area to be treated and making an incision on the facial side of the
most posterior tooth and carrying the incision anteriorly. The lingual
aspect in treated in the same manner. The incision begins at the distal
facial line angle of the most posterior tooth of the arch and is made
optimally at about a forty-five degree angle to the plane of the tooth
forming an inverse bevel. The tip of the cutting instrument remains within
the sulcus. In areas of the mouth where it is difficult to maintain the
forty-five degree angle if the tissue is thin, the practitioner may vary
the range from between zero to forty-five degrees. The incision should
never be a reverse bevel such as is used in the standard gingivectomy. The
incision is reentered at the same inverse forty-five degree angle to
separate the facial, lingual, and papillary tissues from underlying
connective tissue so that the separated tissue may be removed, thereby
removing the coronal portion of the tissue pocket and initially exposing
the root surface. The removal may be performed with a curved mosquito
hemostat or other hand instruments. The tip of the tissue scissors then
rides the base of the pocket and is angled at about a forty-five degree
inverse bevel. The remaining pocket and all soft tissue tags attached to
the incised area are then removed. This step insures the vision to the
clinical apical portion of the pocket thus providing access to bacterial
accretions. Next, gross and fine bacterial accretions and bacterial
endotoxins on the root surface are removed. Application of 30%
trichloracetic acid (TCA) to the facial, lingual, and proximal tissues is
then performed.
Post-treatment procedures to aid healing include, at the seven day period,
light scaling of the treated area, polishing of the treated area with
fluoride prophylaxis material, and application of 30% TCA to the facial,
lingual, and proximal tissues. After about seventeen days following
treatment, light scaling of the treated area is again performed followed
by polishing of the treated area with fluoride prophylaxis material and
application of the 30% TCA. Finally, after about thirty-one days after
treatment, light scaling of the treated area is performed and the treated
area is again polished with fluoride prophylaxis material followed by
application of 30% TCA.
The inventive periodontal procedure results in cessation of the destructive
cycle of periodontal disease by gaining access to the bacteria on the root
surfaces for removal thereof. This procedure is advantageous for several
reasons. The patient has an alternative treatment that can be easier for
the patient to understand when explained by the clinician. The hygienist
is easily and efficiently incorporated into the team approach of
diagnosing. The general dentist who now performs flap surgery also has an
alternative treatment. The patient may be referred to a periodontist
sooner if the general dentist understands that a more conservative
procedure may be performed. This results in an enhanced prognosis. This
novel periodontal procedure may lower dental care costs by reducing the
need for expensive and intricate flap surgeries or for dental specialists
who typically perform more invasive and expensive procedures. The
periodontal procedure allows the general dental practitioner to more
readily perform periodontal treatment at a reduced cost to the patient.
The periodontal procedure may resolve the problem of gaining visual access
to bacteria using a more conservative approach than gingivectomy and
various flap surgery techniques. The novel periodontal procedure is a
non-flap procedure with no reflection of tissue from the tooth. It does
not expose bone, does not require sutures, and the patients can heal with
less post-operative discomfort absent swelling or discoloration.
BRIEF DESCRIPTION OF THE DRAWINGS
The features of the present invention which are believed to be novel are
set forth with particularity in the appended claims. The invention,
together with further objects and advantages thereof, may best be
understood by reference to the following description in conjunction with
the accompanying drawings.
FIG. 1 shows a flowchart depicting the steps involved according to the
inventive method.
FIG. 2a is a drawing depicting an incision made at an inverse forty-five
degree angle according to the inventive method.
FIG. 2b is a drawing depicting the tip of a blade remaining in the sulcus.
FIG. 3 is a drawing depicting separation of facial papillary tissues from
the underlying connective tissue according to the inventive method.
Fig. 4 is a drawing depicting removal of the separated facial papillary
tissue from underlying connective tissue according to the inventive
method.
FIG. 5 is a drawing depicting the tip of the tissue scissors at the base of
the tissue pocket.
FIG. 6 is a drawing depicting the exposed root after removal of the facial
papillary tissue according to the inventive method.
FIG. 7 is a drawing depicting post-operative healing according to the
inventive method.
FIG. 8 is a drawing depicting incisions used in the maxillary anterior
sextant of the papillary region.
DETAILED DESCRIPTION OF THE INVENTION
Referring now to FIG. 1, step 10 shows the start of the method. Initially,
a pre-operative diagnosis must be made indicating application of the
above-described inventive method, as shown in step 12. Once such a
pre-operative diagnosis is made, the clinical step of applying local
anesthetic, as illustrated in step 14 is performed.
Adequate local anesthetic is a prerequisite. Administration of mepivacaine
2% (Carbocaine) with Neo-cobefrin 1:20,000 has been found useful.
Papillary hemostasis is provided by injecting both the lingual and facial
aspects with 2% lidocaine (Xylocaine) with epinephrine 1:50,000 or
1:100,000, or bupivacaine (Marcaine) with epinephrine 1:200,000, depending
on the individual patient's reaction to epinephrine.
Referring now to FIGS. 1, 2a, and 2b, an incision 15 is made relative to
the facial aspect 16, as shown in step 17 of FIG. 1. Beginning at the
distal facial line angle 18 of the most posterior tooth 20 in the arch,
the incision 15 is made at a forty-five degree inverse bevel using an
instrument such as a No. 15 Bard Parker blade 24. However, any suitable
blade may be used. Note that the angle designated as 25 is elevated
forty-five degrees relative to the plane 26 of the teeth in an inverse
manner.
The incision 15 is carried anteriorly to include the papilla and
approximately one to one and one-half millimeters of facial tissue. The
tip 30 of the blade remains within the sulcus 32 as the incision is made.
This process continues until the facial aspect 16 and papilla are incised
using the forty-five degree inverse beveled procedure.
Next, the lingual aspect 34 is incised using the above-described procedure,
as shown in step 38. If two millimeters or less of keratinized gingiva
exists, only the papilla in that area is excised. Now, the tissue is ready
to be detached.
Referring now to FIGS. 1 and 3, the incision 15 is reentered with an
instrument 40 at the same forty-five degree inverse angle 25 as was made
by the initial incision. The instrument 40 may be a No. 1/2 Orban knife,
however any suitable instrument may be used, as shown in step 42 of FIG.
1. This is done to ensure that the facial, lingual, and papillary tissues
are devoid of attachment to the underlying connective tissue 43.
Referring now to FIGS. 1 and 4, gross tissue removal using a hemostat 44
removes the detached tissue 45, as shown in step 46. However, any suitable
instrument may be used.
Referring now to FIGS. 1 and 5, fine pocket reduction is shown in FIG. 5,
as indicated in step 48 of FIG. 1. The tip of a tissue scissor 50 or other
suitable instrument is placed into the remaining pocket 52 at the most
apical point, while carefully maintaining the forty-five degree inverse
angle. The remaining pockets 52 on the facial, lingual, and proximal
regions are then removed and all soft tissue tags (not shown), if any, are
removed. In essence, "riding the base of the pocket" with the tip of the
scissors removes only the surrounding pocket and papillary gingival
tissue. This step completes the site specific surgery for the site
specific destructive disease. As shown in FIG. 6, the required tissue has
been removed exposing the root surfaces 54 to obtain visual access to
disease causing bacteria.
The next step is gross debridement of root surfaces, as illustrated in step
56. Since the bacterial accretions on the root surfaces 54 are now
visually accessible, gross removal of the accretions may be performed with
an ultrasonic scaler. However, any suitable device may be used including
hand scaling instruments.
As shown in step 58, fine debridement of root surfaces 54 further removes
the bacterial accretions from the root surfaces. This is performed with a
hand scaler or non-end cutting bur. As shown in step 60, tissue refinement
may be necessary, at the discretion of the clinician to remove any fine
tissue tags making sure not to increase the width of the wound. This may
be performed with either a No. 15 blade, a No. 1/2 Orban knife, a curette,
or a tissue scissors. However, any suitable instrument may be used. Next,
30% TCA is applied to the facial, lingual, and proximal tissue as shown in
step 64.
Due to the small size of the wound, periodontal dressing is not required.
Alternatively, prescribing an antibiotic and nonsteroidal
anti-inflammatory therapy may complete post-operative protocol.
Chlorhexidine 0.12% (Peridex) rinsing twice per day to promote healing is
prescribed during this appointment.
Referring now to FIGS. 1 and 7, throughout the follow-up period, beginning
at 7 days as shown in step 66, the dentist and hygienist counsels the
patient and reinforces oral hygiene techniques. A light ultrasonic or hand
scaling of the surgical region is then performed. After scaling, the area
is polished with fluoride prophylaxis paste followed by 30% TCA
application to the facial, lingual, and proximal areas. The patient is
then instructed to brush with fluoride toothpaste, to floss gently after
each meal, and to rinse with a fluoride solution. Chlorhexidine 0.12%
(Peridex) rinse is continued until one sixteen ounce bottle is completed.
Seventeen days after surgery, a light scaling is again performed followed
by polishing with fluoride prophylaxis paste followed by TCA 30%
application to the facial, lingual, and proximal surfaces. The patient is
then instructed to use a rubber tip stimulator to further insure proper
oral hygiene.
Thirty-one days after surgery, a light scaling of the surgical area is
repeated followed by polishing with fluoride prophylaxis paste, followed
again by TCA 30% application to the facial, lingual and proximal surfaces.
The patient is further instructed to continue use of the fluoride
toothpaste, floss, and the rubber tip stimulator and to brush
subgingivally with Listerine.RTM.. After the follow-up procedures have
been completed, the procedure is complete, as shown in step 68.
Referring now to FIGS. 1 and 8, the above periodontal procedure, the steps
of which are shown in FIG. 1, is indicated for use in the five sextants of
the mouth. Steps 13 and 38 are modified for use in the maxillary anterior
sextant. For aesthetic reasons, this sextant is treated from the palatal
aspect. The facial tissue is not altered at anytime. In the maxillary
anterior sextant, a second incision 80 is made sulcularly to include only
the palatal one-half of the maxillary anterior papilla. The initial
incision is identically performed on the palatal surfaces. The procedure
is then identical from this point forward to the procedure performed in
the remaining five sextants as described above, as indicated in steps 42
through 68. This allows access to the proximal bacterial accretions from
the palatal aspect without altering the facial tissue, this resulting with
the proper aesthetics.
CASE REPORT
In operation, the inventive periodontal procedure is effective, as shown by
the following case study. The 51-year old patient was referred for
periodontal consultation by her general dentist. Although she had
undergone a course of soft tissue management, generalized pocket depths of
five to six millimeters were recorded. Bleeding and exudate were seen in
response to gentle probing, and radiographs showed horizontal bone loss.
Beginning at the distofacial line angle of the mandibular right second
molar, a sterile No. 15 Bard Parker blade was used to make a forty-five
degree inverse bevel incision with the tip of the blade remaining in the
sulcus. The incision was continued anteriorly to include the papilla and
approximately one to one and one-half millimeters of facial tissue. The
lingual aspect was incised in a similar fashion. The incision was
re-entered with the No. 1/2 Orban knife, giving careful attention to
separating the mesial and distal connective tissue attachment of the
papilla. The excised tissue was then removed with a hemostat. The tip of a
tissue scissor was next used at the same inverse bevel forty-five degree
angle to remove the remaining pocket and soft tissue tags on the affected
root surfaces. The root surfaces were then completely debrided. No
periodontal dressing was placed over the surgical site and the patient
returned for follow-up appointments and was treated as described above.
Post-operative healing was uneventful. At the thirty-one day
post-operative appointment, it was evident that the five to six millimeter
pockets had been replaced by one to two millimeter healthy sulci.
A specific embodiment of the periodontal procedure according to the present
inventive method has been described for the purpose of illustrating the
manner in which the method may be used. It should be understood that
implementation of other variations and modifications of the method and its
various aspects will be apparent to those skilled in the art, and that the
method is not limited by the specific embodiment described. It is
therefore contemplated to cover by the present method any and all
modifications, variations, or equivalents that fall within the true spirit
and scope of the basic underlying principles disclosed and claimed herein.
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